Influenza is responsible for nearly 20,000 deaths per year in the U.S. The cause-specific mortality rates are highest among persons aged 65 years or older and those with chronic illnesses. Patients 50 to 64 years of age are more likely to have chronic diseases, which increases their risk of influenza.

Influenza vaccinations are associated with reductions in influenza-related respiratory illness, hospitalizations, and deaths in these high-risk populations. The vaccine is approximately 58% effective in uninstitutionalized adults older than age 60, but the vaccine’s efficacy is further decreased in adults older than age 70. The vaccine is also effective in preventing hospitalization for pneumonia and influenza.
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In two studies of elderly patients living outside nursing homes and long-term care facilities, the influenza vaccine was 30% to 70% effective at preventing hospitalization. In one study of institutionalized patients, the vaccine helped 50% to 60% of patients avoid hospitalization for pneumonia. These studies demonstrate the potential health care savings of successful vaccination programs.

Cases of influenza are most commonly reported during the winter months, particularly from November until March. For this reason, vaccination campaigns are usually undertaken in October and November (known as the influenza season).

Adults at the highest risk of morbidity should be vaccinated first. The ACIP recommends that the following groups be vaccinated in October regardless of the setting in which the vaccination is given:

  • persons at increased risk for influenza-related complications (those over 65 years of age, those aged six months to 64 years with certain medical conditions, and healthy children aged six to 23 months)
  • health care workers
  • household contacts of persons at increased risk for influenza-related complications (including contacts of infants younger than six months of age who are not eligible for influenza vaccine)
  • children aged six months to up to nine years of age who are receiving influenza vaccine for the first time
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If patients are not vaccinated in October or November, vaccination should still be offered throughout the influenza season. Older people and patients with chronic disease may develop lower post-vaccination titers to influenza than healthy young adults and therefore are more susceptible to influenza-related infections. This makes aggressive vaccine campaigns even more important for the elderly population.

Influenza is a rapidly evolving and changing virus. Different strains may be responsible for epidemics from year to year. For this reason, the influenza vaccine is reformulated each year to include the strains that are most likely to be encountered in a given “flu” season.

The vaccine is composed of inactivated virus grown in purified egg protein. Products may differ in preservative composition and quantity among manufacturers. The 2002-2003 tri-valent vaccine virus strains are A/Moscow/10/99 (H3N2)-like, A/New Caledonia/20/99 (H1N1)-like, and B/Hong Kong/ 330/2001-like strains, which were forecasted to be the most likely strains encountered in the U.S. in the 2002-2003 season.

Typically, vaccine manufacturers begin shipping the influenza vaccine in late September each year, but most companies require advanced orders of the desired vaccine. Thus, program administrators must be able to anticipate precise quantities of vaccine that will be needed for both patients and health care providers. Manufacturers begin to accept influenza vaccine orders in early March for the upcoming flu season. A representative from one large manufacturer of flu vaccine reported that during the spring of2002, the company had stopped accepting orders by early April. For this reason, it is important to determine the extent of use of the previous year’s product at the end of the flu season and to anticipate needs for the coming year’s campaign.

The first shipment of influenza vaccine is sent in September; generally, this delivery constitutes about 50% of the total order for the institution. The second shipment, which makes up an additional 25% of the total order, arrives in mid to late October, and the final shipment is sent in early November. Because there have been several shortages of influenza vaccine in recent years, it is important to note that underestimating the need for vaccine can result in inadequate supplies and a lack of opportunities to restock.

Pneumococcal Polysaccharide Vaccine

Streptococcus pneumoniae (pneumococcus) infection is the leading cause of death among vaccine-preventable bacterial diseases in the U.S. Those who are most at risk for contracting pneumococcal invasive disease are children younger than two years of age, adults older than 65 years of age, and patients with chronic medical disorders (e.g., diabetes, cardiovascular, liver, kidney, lung, or immune system disease).

Pneumococcus is the most commonly identified pathogen in elderly patients with pneumonia. For example, the incidence of pneumococcal bacteremia in renal transplant recipients is nearly double that of the general population. Each year, pneumococcal disease causes approximately 500,000 cases of pneumonia in the U.S., with 10% to 25% of cases resulting in bacteremia. An alarming 30% to 40% of pneumo-coccal bacteremia cases in the elderly result in death. According to the ACIP, approximately half of these deaths have the potential to be prevented through the use of vaccine.

A study of the cost-effectiveness of the pneumococcal vaccine estimated that for people aged 65 years and older, vaccination resulted in net medical cost savings of $8.27 and in a gain of 1.21 quality-adjusted days of life per person vacci-nated. In the authors’ cost-effectiveness model, 23 million elderly people who remained unvaccinated in 1993 would have gained about 78,000 years of healthy life and would have saved $194 million if they had received the vaccine. This demonstrates the importance of an effective pneumococcus vaccine campaign targeted at adults over age 65.
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Two vaccines are currently used to protect patients from invasive pneumococcal disease:

  • PPV-23, a 23-valent pneumococcal polysaccharide vaccine. PPV-23 contains 23 antigens from bacterial capsular protein types and represents at least 90% of the serotypes that cause invasive pneumococcal infections among children and adults in the U.S. PPV-23 is used to immunize adults and children over two years of age against pneumococcal disease.
  • PCV-7, a 7-valent pneumococcal conjugate vaccine. PCV-7 is designed to enhance immunogenicity in children younger than two years of age. The capsular proteins represented in this vaccine protect against the serotypes that are most likely to cause invasive pneumococcal disease in children younger than age two years. PCV-7 is not recommended for older adults.

The effectiveness of PPV-23 against invasive pneumococcal disease has been assessed in several case-control studies. PPV-23 has been found to be 56°% to 81°% effective; in these studies, patients older than age 65 tended to demonstrate higher effectiveness rates than younger patients did, probably because of an increase in the prevalence of invasive pneumo-coccal disease in the elderly population. In 80% of healthy young adults, the PPV-23 vaccine creates a two-fold rise in antigen-specific titers. However, this immunological effect can vary for different serotypes that are represented in the vaccine. In addition, the optimal antibody response that correlates with protection against pneumococcal invasive disease has not been clearly defined. Thus, pneumococcal titers may not predict protection against invasive disease.

Although pneumococcal antibody concentrations persist for five years in healthy adults before these levels decline, older adults and patients with certain chronic health problems experience a rapid decline, with prevaccination levels observed after five to 10 years. Other groups of patients who have experienced rapidly declining levels of antibodies include those who have undergone a splenectomy following trauma and patients with hematological disorders. tadacip

The ACIP recommends PPV-23 for the following groups of elderly people:

  • adults aged 65 years or older, with all persons in this category to receive the pneumococcal vaccine, including previously unvaccinated persons
  • adults who have not been vaccinated within five years (and who were younger than 65 years of age at the time of vaccination)
  • all adults whose vaccination status is unknown (one dose of vaccine recommended)
  • adults with chronic health problems such as diabetes, cardiovascular disease, functional or anatomic asplenia, and lung disease
  • immunocompromised patients of any age

Clinicians must carefully assess patients’ vaccination histories so that they can determine who should receive the pneumococcal vaccine. The ACIP has developed an algorithm (Figure 1) to assist clinicians in determining pneumococcal vaccine candidates among the elderly.

PPV-23 can be administered via the subcutaneous (SQ) or the intramuscular (IM) route as a single 0.5-ml dose. Especially important for elderly adults, PPV-23, influenza vaccine, and diphtheria/tetanus toxoid can be administered simultaneously without any decrease in efficacy. This strategy can help to prevent a missed opportunity to administer other vaccines that the patient needs.